Thyroid and Parathyroid Disorders - Umar Zein

Thyroid and Parathyroid
Disorders – Umar Zein

THYROID GLAND
DISORDERS
THYROID GLAND DISORDERS
 GENERAL ASPECTS OF THYROID GLAND
– Anatomy: weight range from 12 to 30g

– Located in the neck, anterior to the
trachea
– Produces: T4 & T3 (active hormone)
– Regulation: “negative Feed-back” axis
– THYROID GLAND REGULATION
“negative Feed-back” axis
– Hypothalamus
(negative
effect)
(TRH positive effect)
– Pituitary gland
(TSH, positive effect)
– Thyroid gland
T3 & T4
 Thyroid hormones:
– T4: (Thyroxine) is made exclusively in

thyroid gland
• Ratio of T4 to T3 ; 5:1
• Potency of T4 to T3; 1:10
• T4 is the most important source of T3 by

peripheral tissue deiodination “ T4 to T3 “
 Thyroid hormones:
– T3: (Triiodothyronine) main source is

peripheral deiodination:
• Ratio of T3 to T4 ; 1:5
• Potency of T3 to T4; 10:1
• T3 is the most important because more than

90% of the thyroid hormones physiological
effects are due to the binding of T3 to
Thyroid receptors in peripheral tissues.
PHYSIOLOGY EFFECTS
OF THYROID HORMONES
 THEY ARE NOT ESSENTIAL

FOR LIFE, BUT ARE
EXTREMELY HELPFUL
 THYROID HORMONE EFFECTS:
– Affects every single cell in the body
• Modulates:
– Oxygen consumption
– Growth rate
– Maturation and cell differentiation
– Turnover of Vitamins, Hormones, Proteins,
Fat, CHO
 MECHANISMS OF THYROID
HORMONE ACTION
– Act by binding to Nuclear receptors,

termed Thyroid Hormone Receptors
(TRs), Increasing synthesis of proteins
– At mitochondrial level increases

number and activity to increasing ATP
production
– At Cell membrane increases ions and

substrates transmembrane flux
 THYROID HORMONE EFFECTS
– CALORIGENESIS
– GROWTH & MATURATION RATE
– C.N.S. DEVELOPMENT & FUNCTION
– CHO, FAT & PROTEIN METABOLISM
– MUSCLE METABOLISM
– ELECTROLYTE BALANCE
– VITAMIN METABOLISM
– CARDIOVASCULAR SYSTEM
– HEMATOPOIETIC SYSTEM
– GASTROINTESTINAL SYSTEM
– ENDOCRINE SYSTEM
– PREGNANCY
– CALORIGENESIS
• Controls the Basal Metabolic Rate (BMR)
– CHO METABOLISM
• Increases:
– Glucose absorption of the GI tract
– Glucose consumption by peripheral tissues
– Glucose uptake by the cells
– Glycolysis
– Gluconeogenesis
– Insulin secretion
– GROWTH & MATURATION RATE
– C.N.S. DEVELOPMENT & FUNTION
• “ESSENTIAL” in the newborn to prevent

development of “CRETINISMS” & to a
normal “IQ”
• Modulation of brain cerebration
• Mood modulation
- FAT & PROTEIN METABOLISM
• Increase lipolysis and lipid mobilization with:
– Cholesterol
– Triglicerides
– Free fatty acids
– MUSCLE METABOLISM
• Modulates;
– Strength & velocity of contraction

– ELECTROLYTE BALANCE
• Low Thyroid hormones could induce

hyponatremia
– VITAMIN METABOLISM
• Modulates vitamin consumption
– HEMATOPOIETIC SYSTEM
• Could induce anemia

– CARDIOVASCULAR SYSTEM
• Hyperthyroidism, increases:
– Heart rate & myocardial strenght
– Cardiac output
– Peripheral resistances (Vasodilatation)
– Arterial pressure
• Hypothyroidism, reduces:
– Heart rate & myocardial strenght
– Cardiac output
– Peripheral resistances (Vasodilatation)
– Arterial pressure
– GASTROINTESTINAL SYSTEM
• Modulate bowel movements and absorption
– ENDOCRINE SYSTEM
• Modulates pituitary axis, affecting GH,

ACTH, FSH, LH, so-on
– PREGNANCY
• Modulates growth rate and affects lactation

 DIVIDED INTO:
– THYROTOXICOSIS (Hyperthyroidism)
• Overproduction of thyroid hormones
– HYPOTHYROIDISM (Gland destruction)

• Underproduction of thyroid hormones
– NEOPLASTIC PROCESSES
• Beningn
• Malignant
 LABORATORY EVALUATION
TSH normal, practically excludes abnormality
– If TSH is abnormal, next step: Total & Free T4 & T3
- TSI (Thyroid Stimulating Ig)
- TPO (Thyroid Peroxidase Ab)
- Antimitochondrial Ab
- Serum Tg (Thyroglobulin)
- Radioiodine uptake & Thyroid scaning
- FNA, Fine-needle aspiration
- Thyroid ultrasound
 TSH High usually means Hypothyroidism
– Rare causes:
• TSH-secreting pituitary tumor
• Thyroid hormone resistance
• Assay artifact
 TSH low usually indicates Thyrotoxicosis
– Other causes
• First trimester of pregnancy
• After treatment of hyperthyroidism
• Some medications (Esteroids-dopamine)
 THYROTOXICOSIS:
– is defined as the state of
thyroid hormone excesss
 HYPERTHYROIDISM:
– is the result of excessive
thyroid gland function
 Abnormalities of Thyroid Hormones
– Thyrotoxicosis
• Primary
• Secondary
• Without Hyperthyroidism
• Exogenous or factitious
– Hypothyroidism
• Primary
• Secondary
• Peripheral
 Causes of Thyrotoxicosis:
– Primary Hyperthyroidism
• Grave´s disease
• Toxic Multinodular Goiter
• Toxic adenoma
• Functioning thyroid carcinoma
metastases
• Activating mutation of TSH receptor
• Struma ovary
• Drugs: Iodine excess
 Causes of Thyrotoxicosis:
– Thyrotoxicosis without hyperthyroidism
• Subacute thyroiditis
• Silent thyroiditis
• Other causes of thyroid destruction:
– Amiodarone, radiation, infarction of an
adenoma
• Exogenous/Factitia
– Secondary Hyperthyroidism
• TSH-secreting pituitary adenoma
• Thyroid hormone resistance syndrome
• Chorionic Gonadotropin-secreting tumor
• Gestational thyrotoxicosis
THYROTOXICOSIS
 Symptoms:  Signs:
– Hyperactivity – Tachycardia
– Irritability – Atrial fibrillation
– Dysphoria – Tremor
– Heat intolerance & – Goiter
sweating – Warm, moist skin
– Palpitations – Muscle weakness,
– Fatigue & weakness myopathy
– Weight loss with – Lid retraction or lag
increased appetite – Gynecomastia
– Diarrhea – * Exophtalmus
– Polyuria – * Pretibial
– Sexual dysfunction myxedema
Struma
- diffusa
- noduler ---- multi noduler
Konsistesi: lunak, kenyal, keras
Batas: tegas, tdk tegas
Nyeri tekan : (+) a (-)
Mobilitas : mobile a immobole
Struma: toksik a non toksik
Toksis = trotoksikosis =
hyperthroidism
Struma diffusa toksik = grave’s
disease
Struma noduler toksik
Thyroiditis – Hashimoto
thyroiditis
 Differential diagnosis:
– Panic attacks
– Psychosis
– Mania
– Pheochromocytoma
– Hypoglycemia
– Occult malignancy
PTU 100 mg/tab
Neomercazole
 propranolol
 operatif : strumectomy
 radionuclide therapy
 Treatment:
– Reducing thyroid hormone synthesis:

• Antithyroid drugs (Methimazole, Propylthyouracil)
• Radioiodine (131I)
• Subtotal thyroidectomy
– Reducing Thyroid hormone effects:

• Propranolol
• Glucocorticoids
• Benzodiazepines
– Reducing peripheral conversion of T4 to T3

• Propylthyouracil
• Glucocorticoids
• Iodide (Large oral or IV dosage) (Wolf-Chaikoff
effect)
 Treatment: Special considerations:
– Thyrotoxic crisis or Thyroid storm:

• It´s a life-threatening exacervation of thyrotoxicosis,
acompanied by fever, delirium, seizures, coma,
vomiting, diarrhea, jaundice.
• Mortality rate reachs 30% even with treatment
• It´s usually precipitated by acute illness, such as:
– Stroke, infection,trauma, diabeic ketoacidosis,

surgery, radioiodine treatment
• Propylthyouracil IV or Nasogastric tube

• Radioiodine (131I)
• Propranolol
• Glucocorticoids
• Benzodiazepines
• Iodide (Large oral or IV dosage) (Wolf-Chaikoff
effect)
 HYPOTHYROIDISM
– Primary
• Autoimmune (Hashimoto´s)
• Iatrogenic Surgery or 131I
• Drugs: amiodarone, lithium
• Congenital (1 in 3000 to 4000)
• Iodine defficiency
• Infiltrative disorders
 Hashimoto´s Thyroiditis or
Goitrous thyroiditis

– Mean anual incidence:
• Women 4:1000 Men 1:1000
• Risk factors; TPO antibodies (90%)
Japanese, previous history, high I
intake
• Average age: 60
• Frequently associated to other
autoimmune disorders such as: AR,
SLE, Sjogren´s so-on.
• Treatment: Levothyroxine
 CONGENITAL HYPOTHYROIDISM
 Prevalence: 1 in 3000 to 4000 newborns

– Cause: Dysgenesis 85%
– Dx: Blood screning (TSH &/or T4)
 Treatment:
– Supplemental Tx. With Levothyroxine is
“essential” for a normal C.N.S.
Development and prevention of mental
retardation
 HYPOTHYROIDISM
– Secondary
• Pituitary gland destruction
• Isolated TSH deficiency
• Bexarotene treatment
• Hypothalamic disorders
– Peripheral:
• Rare, familial tendency
HYPOTHYROIDISM
 Symptoms:  Signs:
– Bradycardia
– Tiredness – Dry coarse skin
– Weakness – Puffy face, hands
– Dry skin Sexual and feet
– Diffuse alopecia
dysfunction
– Peripheral edema
– Dry skin – Delayed tendon
– Hair loss reflex relaxation
– Carpal tunel
– Difficulty syndrome
concentrating – Serous cavity
effusions.
 SPECIAL TREATMENT CONSIDERATIONS
 Myxedema coma
– Reduced level of consciousness, seizures
– Hypotension/shock
– Hypothermia
– Hyponatremia
 Usually in elderly hypothyroid pts.
 Usually precipitated by intercurrent illnesses that

impairs ventilation
 It´s an Emergency with a high mortality rate
 Treatment: Lyotironine(T3) or T4, Hydrocortisone,

external warming, IV fluids
 SPECIAL TREATMENT CONSIDERATIONS
 Elderly patients
 Coronary Artery Disease
 Poor adrenal gland reserve
 Childrens
 Pregnancy
 Emergency surgery (Non thyroid related)

 THYROID GLAND NEOPLASIAS
 Out of the focus of this lecture

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Thyroid and Parathyroid

Disorders – Umar Zein

– Anatomy: weight range from 12 to 30g

(TSH, positive effect)

– T4: (Thyroxine) is made exclusively in

• Potency of T4 to T3; 1:10

• T4 is the most important source of T3 by

– T3: (Triiodothyronine) main source is

• Potency of T3 to T4; 10:1

• T3 is the most important because more than

 THEY ARE NOT ESSENTIAL

– Affects every single cell in the body

– Act by binding to Nuclear receptors,

– At mitochondrial level increases

– At Cell membrane increases ions and

– GROWTH & MATURATION RATE

– C.N.S. DEVELOPMENT & FUNTION

• “ESSENTIAL” in the newborn to prevent

• Modulation of brain cerebration

- FAT & PROTEIN METABOLISM

• Increase lipolysis and lipid mobilization with:

– Strength & velocity of contraction

• Low Thyroid hormones could induce

• Modulates vitamin consumption

• Could induce anemia

• Modulate bowel movements and absorption

• Modulates pituitary axis, affecting GH,

• Modulates growth rate and affects lactation

– HYPOTHYROIDISM (Gland destruction)

– If TSH is abnormal, next step: Total & Free T4 & T3

- TSI (Thyroid Stimulating Ig)

- TPO (Thyroid Peroxidase Ab)

- Radioiodine uptake & Thyroid scaning

- FNA, Fine-needle aspiration

 TSH low usually indicates Thyrotoxicosis

– Reducing thyroid hormone synthesis:

– Reducing Thyroid hormone effects:

– Reducing peripheral conversion of T4 to T3

– Thyrotoxic crisis or Thyroid storm:

• It´s usually precipitated by acute illness, such as:

– Stroke, infection,trauma, diabeic ketoacidosis,

• Propylthyouracil IV or Nasogastric tube

 Prevalence: 1 in 3000 to 4000 newborns

 Usually in elderly hypothyroid pts.

 Usually precipitated by intercurrent illnesses that

 It´s an Emergency with a high mortality rate

 Treatment: Lyotironine(T3) or T4, Hydrocortisone,

 Coronary Artery Disease

 Poor adrenal gland reserve

 Emergency surgery (Non thyroid related)

 THYROID GLAND NEOPLASIAS

 Out of the focus of this lecture

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